NCLEX-RN
Practice NCLEX RN Test Questions
Extract:
Question 1 of 5
The physician has made a diagnosis of 'shaken child' syndrome for a 13-month-old who was brought to the emergency room after a reported fall from his highchair. Which finding supports the diagnosis of 'shaken child' syndrome?
Correct Answer: C
Rationale: Retinal hemorrhages are a hallmark of shaken baby syndrome due to the shearing forces from violent shaking causing bleeding in the retina.
Question 2 of 5
The nurse is taking care of an elderly client with congestive heart failure. Which of the following are the most appropriate nursing interventions to reduce the workload of the heart and to promote comfort and rest? Select all that apply.
Correct Answer: A, B, D
Rationale: Daily weights monitor fluid status, assistance with self-care reduces exertion, and post-activity vital signs assess heart workload. Sensory stimulation may increase stress.
Question 3 of 5
The nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The nurse notes that the urine output is bright red with clots. Which of the following actions should the nurse take FIRST?
Correct Answer: B
Rationale: bright red urine with clots indicates potential bleeding, requiring immediate physician notification
Question 4 of 5
A child suspected of having cystic fibrosis is scheduled for a quantitative sweat test. The nurse knows that the quantitative sweat test will be analyzed using:
Correct Answer: A
Rationale: Pilocarpine iontophoresis is used to stimulate sweat production for chloride analysis in cystic fibrosis diagnosis.
Question 5 of 5
The nurse is assigned to care for the client with a Steinmen pin. During pin care, she notes that the LPN uses sterile gloves and Q-tips to clean the pin. Which action should the nurse take at this time?
Correct Answer: A
Rationale: Sterile technique is appropriate for pin care; assisting maintains the sterile field.